Gleason 9: PSA .5 at 6 weeks post RALP

First time to post here…I’m a very worried wife. My 59 year old and seemingly healthy and active husband had RALP almost 6 weeks ago and his first PSA result came back at .5. His pre surgery PSA was 7.98. This was a punch in the gut for both of us hoping that his number would be undetectable.

From his post surgical pathology report: Gleason 9, Grade 5, percentage of pattern 4 is 75%, percentage of pattern 5 is 15%. Cribiform present, left anterior EPE, and perineural invasion. Margins were all negative and no lymph or distant metastasis. No SVI present. Stage: pT3a. PET scan prior to surgery was also clear.

Is there a chance his PSA will drop to undetectable or is he looking at further treatment?

Post Edited (JLR65) : 12/17/2022 8:44:42 PM (GMT-8)

Ugggh.

You can never say never (e.g there may have been a lab error) but 0.5 is not great news 6 weeks out, but it could be worse.

The definitive test is at 3 months.

Heal up. Start looking around for a radiation oncologist. Assuming the 0.5 holds the next step will likely be some combination of:
- a psma pet scan to try and identify the source
- radiation to at least the prostate bed but since he is a g9 they might recommend also doing full pelvic radiation to treat nearby lymph nodes with or without a hit on the psma scan
- a temporary period (anywhere between 6 and 24 months) of hormone therapy along with the radiation to increase the chances of a durable remission/cure.

Yes I indeed said the word cure in that sentence.

You took a mighty swing and you still have some good swings to take (if necessary).

Do not lose heart.

Hello and welcome to the Forum. While it is possible your husband's PSA will drop further, with that post-op report and 6-week PSA value, I think he will likely need adjuvant therapy to complete his primary treatment. This has generally been the case for Gleason 9-10 men with one ore more major adverse findings, such as EPE, even those men with an undetectable post-op PSA.

The results of recent studies are changing the standard of care from adjuvant towards early or very early salvage therapy for many men G7-8 men who have adverse findings but undetectable post-op PSA (that is, holding off further treatment to see if an undetectable PSA rises). However, I believe the jury is still out for very-high risk men. On the other hand, if your husband does have persistent PSA (upcoming readings that do not go down and drop below 0.1), then I believe waiting beyond a short healing period is not the best option and that he and will be advised to have further therapy, e.g., RT possibly with ADT.

What was the tumor burden noted in the report (the percentage of prostate involved by the cancer)?

Note that persistent PSA means that prostate tissue and possible (micro)metastases were left behind, but it does not rule out that all remaining tissue is currently located in the pelvis and that RT can complete a successful treatment and put the cancer behind him. Although a post-RP path report does not address distant metastases (only local lymph nodes are sampled), his pre-op imaging was promising in this regard, although every imaging method has a limit of resolution, below which tiny mets will not show up.

You might discuss a Decipher test with his doctor. It looks at the RNA in the cancer removed in the RP and gives you the risk (low, intermediate, high) of metastases within 5 years. Not all G9 prostate cancers are equal with regard to met risk. This result might help with treatment planning (e.g., length of any ADT therapy planned or the size of the pelvic radiation field). Please remember that we are not doctors, so I would take Forum advise and experience as guidance about the topics you should discuss with his medical team.

Please keep us posted and all the best!

Djin

JLR65 said...
Knowing what the next steps may be and having an action plan help relieve the anxiety of this experience.

JLR65,
Yep, you nailed it. A plan, and focusing the next step, really can keep the anxiety down. Good luck with your husband's treatment and I'm glad you're advocating for him.

It's very likely that he will need radiation therapy. It would make sense for you to read up on radiation treatments for prostate cancer so that, when you end up talking to a radiation oncologist, you will understand what he/she is saying, and know what questions to ask.

I suggest you do several things:

1. Get another PSA test next weeks. PSA half life is 2-3 days. It’s either going down or it isn’t.
2. Get a second opinion on the pathology report.
3. Get a second opinion of the PET scan.
4. Get a Decipher test.
5. Get another PET scan using a different tracer.
6. Wait for radiation and/or ADT until you know where the cancer is.
7. Find the best urologic oncologist you can at a Cancer Center of Excellence.